Heimlich's Maneuvers

  Dr. Winfield was a friendly man who listened attentively as I described the reversed gastric tube operation’s concept. He asked some pertinent questions and said he would consider it. A few weeks later, he called me: “We can make you a clinical assistant professor in surgery so you can conduct this research. There’s no pay, but you’ll have access to the animal lab and a three-hundred-dollar grant.”

  I could hardly contain my excitement. This was the chance I had been looking for. Now I had access to a lab where I could truly test my idea to see if it did in fact allow people with dysphagia to be able to swallow.

  SUCCESS IN THE LABORATORY

  In 1954, I began a series of experiments to test the efficacy of the reversed gastric tube operation with dogs. With such a limited budget, I couldn’t afford to hire any assistants, so I did all the work myself. The first attempt took eight or nine hours, and, sadly, the dog died. I experimented on a second dog, and it died, too. I didn’t believe that their deaths were caused by a problem with the technique but rather the prolonged surgery and technical difficulties due to the fact that I was taking on too much myself. I obviously needed help. Things began to look up after I piqued the interest of a bright, young Mount Sinai resident who volunteered to help me on his days off. With his assistance, the subsequent procedures went faster and easier, and, thereafter, the dogs lived.

  After a couple of days, I felt that a dog who had undergone the procedure might be ready to try drinking. I gave the dog some milk, and he drank it. I was hopeful. A few days later, I tried small amounts of meat, and the dog was able to eat. I knew then that the reversed gastric tube operation had strong potential to overcome dysphagia. But there was still one more test to do. Three weeks after the operation, I inserted barium into the dog’s throat to trace its swallowing activity, and an x-ray showed the reversed gastric tube was functioning as a normal esophagus.

  Figure 9.3. In the laboratory: I spent many hours in the laboratory, perfecting what would come to be known as the reversed gastric tube operation.

  After I successfully completed the procedure on six dogs, I authored a paper along with Dr. Winfield, describing the results. “The Use of a Gastric Tube to Replace or By-Pass the Esophagus,” published in Surgery in 1955,1 was my first scientific paper. I knew that it was time to try out the reversed gastric tube operation on a human patient. It took a while before we had the right candidate. One day, a sixty-four-year-old patient with a metastasized cancer of the esophagus was admitted to Metropolitan Hospital, one of the three hospitals affiliated with New York Medical College. His esophagus was blocked by cancer, and he could no longer swallow food. I requested permission to perform the procedure. The hospital, chief of surgery, and patient all gave their consent. In August 1957, I replaced the cancerous part of the man’s esophagus using my reversed gastric tube method. The procedure went beautifully, and, within two weeks, the patient was eating solid food. The man reported in April of 1958 that he was comfortable and able to eat without difficulty.

  I was eager to tell my colleagues about this new procedure that had given the patient a newfound ability to eat. I presented the patient’s case at the weekly surgical meeting in front of some thirty surgeons at New York Medical College. I felt sure the other surgeons would be ecstatic about my discovery.

  After I described the operation, the patient was brought to the conference room. I had already arranged for an orderly to bring in a sandwich and a cup of coffee, which now sat in front of the patient. After describing his history, physical findings, and the reversed gastric tube operation, I said to him, “Please, go ahead and take a bite of your sandwich.”

  The patient eyed the sandwich before him.

  “I can’t eat,” he said. Much to my chagrin, I heard roars of laughter among the surgeons. I waited for the laughter to subside.

  “Sir, I saw you eat yesterday. Why can’t you eat?”

  “Because they didn’t bring my teeth up from my room!” he bellowed. I smiled and asked the orderly to fetch the man’s dentures. The room was silent.

  We all waited until the orderly returned with the dentures and gave them to the patient. He then put them in his mouth, picked up the sandwich, took a big bite, and methodically chewed. When he was ready, the patient swallowed, and the bite of sandwich went down easily. The man smiled grandly and took another bite. Another swallow. Another smile. I myself was all grins, too. But, as the patient finished the sandwich, I couldn’t help noticing that the doctors at the meeting just sat there glumly, none of them uttering a word.

  I was ecstatic that I had proven that the reversed gastric tube operation could restore a patient’s ability to eat. But, at the same time, I was disheartened that none of the surgeons seemed to appreciate my achievement. Still, I grew to expect this kind of rejection. In fact, when the reversed gastric tube procedure first became known, physicians seemed loathe to endorsing it or even acknowledging its benefits. Chiefs of surgery seemed to resent my work. At national surgical meetings, prominent surgeons bitterly spoke out against the procedure. (Many years later, I realized that, in the case of the reversed gastric tube operation, I had committed a medical faux pas, for I had not included my chiefs of surgery as authors of most of my papers. The practice of tying others to one’s work, known as “academic slavery,” was customary, even though the secondary physicians had not actually contributed to the work. I had committed a cardinal sin in the medical profession by not including their names.)

  PATIENTS BENEFIT FROM THE REVERSED GASTRIC TUBE OPERATION

  Soon, more and more physicians were finding out about the procedure—some surgeons were performing it—and other doctors referred to me patients who needed it. I remember the case of one patient in particular. Fifty-two-year-old Virginia Dixon had been in her early twenties when she had accidentally swallowed lye, leaving her esophagus scarred and blocked. Several attempts had been made to open the damaged part of her esophagus, but none had worked. For those twenty-nine years of not being able to swallow, Ms. Dixon fed herself in a way that most of us would think would severely cramp her quality of life. At each meal, she attached a funnel to a large, rubber feeding tube that had been surgically inserted into her stomach. Then she would chew her food, remove it from her mouth, and put it into the funnel so it could find a way to her stomach. Understandably, eating was a source of stress for Ms. Dixon, both emotionally and physically, for if food reached the back of her throat, she would choke and gag. Saliva pooled in the back of her throat, so she had to spit frequently.

  Remarkably, Ms. Dixon hid her disability from her coworkers for decades by taking her tube feedings in a stall in the ladies’ room at the office where she worked. Like many victims who are unable to swallow, her abnormal eating practices made it impossible for her to enjoy meals with family and friends. Yet Mrs. Dixon was a courageous, happy person who was married with two children. I felt humbled and privileged each time I spoke to this impressive woman.

  In 1959, Ms. Dixon entered Montefiore Hospital and I performed the reversed gastric tube operation on her. Two weeks later, I brought Ms. Dixon a dish of gelatin. The gelatin product’s flavor and texture helped patients who had not swallowed in a long time get the food down their throats without gagging or aspirating. The hospital photographer was present as Ms. Dixon raised the spoon to her lips, capturing in three pictures her experience of swallowing for the first time in twenty-nine years: In the first photograph, she is inserting a spoonful of gelatin into her mouth and appears dubious. In the second photo, she looks grim as she hesitates before actually swallowing. In the third photo, she has a joyful, broad smile and her eyes are gleaming as the gelatin goes down. The series of shots was published around the world.

  Figure 9.4. The swallow heard ’round the world: Virginia Dixon was one of the first patients to undergo the reversed gastric tube operation. The media widely covered her first time eating in nearly thirty years.

  Cosmopolitan magazine picked up the story. Protecting Ms. Dixon’s identity, the
article used the fictitious name, “Mrs. Dennis.” The article was titled “Mrs. Dennis and the Miraculous Meal” and was written by esteemed medical writer Lawrence Galton. Mr. Galton described the process of the operation, which was followed by artificial-tube feedings while the body healed. “Then came the longed-for time—the first day of swallowing,” Mr. Galton wrote:

  Tentatively, she put it [the gelatin] in her mouth and tasted it, then looked at the nurse and doctor. Finally, she swallowed it—and gasped with delight. It was the first time in twenty-nine years that she had had the simple satisfaction of swallowing food.

  An ingenious operation had made it possible—an operation which gave her a new esophagus, that tube which connects the pharynx with the stomach. And, that operation now promises to make possible normal lives for many cancer victims and for those who are injured from swallowing lye.2

  Word continued to spread about what the media was calling the “Heimlich Reversed Gastric Tube operation.” By this time, the procedure did not take as long as when I first performed it, thanks to a device developed by a Japanese physician specifically for the reversed gastric tube operation after he heard me give a lecture on it in Japan in 1958. The Izukura stapling instrument sped up the procedure by inserting two rows of staples that closed the incisions made to the stomach.

  On July 7, 1961, an article appeared in Life magazine, whose caption called the procedure a “Hot Medical Discovery.”3 It shows a picture of me demonstrating the operation at an exhibit during a conference of the American Medical Association. At the exhibit, a patient who had undergone the procedure sat nearby, and I stood in our booth, talking to the doctors who approached. My dear friends Bernie and Ronnie Birnbaum had helped put it all together. Bernie, a producer at CBS, had assisted me in designing the exhibit, and Ronnie, who was a puppeteer, had constructed to my specifications a cloth model of a stomach, complete with zippers that showed how each step of the procedure is done. (Years later, my twin daughters, Janet and Elisabeth, would play with the model when they were young, although they had no idea what it represented.)

  My good friend Paul Winchell, the famous ventriloquist, was also there. Paul had always loved medicine. Before he became an entertainer, he helped me educate other doctors about my reversed gastric tube operation. Paul frequently made rounds with me and made interesting suggestions in regard to patient care.

  Figure 9.5. Telling the world about the Heimlich reversed gastric tube operation: I was eager to talk about this procedure that could restore patients’ ability to swallow.

  Figure 9.6. An eager assistant: Before he became a famous ventriloquist, Paul Winchell, who loved medicine, helped me educate other doctors about my reversed gastric tube operation.

  AN INFANT UNDERGOES THE PROCEDURE

  But even as the reversed gastric tube operation achieved great success, there was still a group of important candidates for the operation who had not yet benefited from it: children. There are different ways that children become inflicted with dysphagia. For example, some drink a caustic substance that burns and scars the esophagus. Some infants are born with a birth defect known as a tracheoesophageal fistula, in which the esophagus is attached to the trachea, thereby preventing the patients from being able to swallow food or liquids. To make matters worse, this condition causes them to inhale saliva into their lungs, causing pneumonia. One such infant was Guy Carpico.

  Guy was born at Syosset Hospital in Long Island, New York, on December 24, 1965. Due to his tracheoesophageal fistula, Guy’s esophagus was sealed off. Not only was Guy unable to swallow, he also had trouble breathing. Because his esophagus and trachea were connected, saliva would enter Guy’s lungs, leaving him in danger of drowning in his own fluids. Guy’s mother was referred by a physician who knew how I had helped other patients with severe swallowing problems. And so Guy was brought to Montefiore Hospital and put under my care when he was three days old.

  Restoring Guy’s ability to swallow was extremely complicated, much more so than other reversed gastric tube operations I had performed. Not only was I dealing with a very small body, but he also required seven operations both to correct the esophageal blockage and just to keep him alive. During his stay, the hospital staff had grown fond of Guy—one nurse refused to take a vacation until he was out of danger. I grew close to the infant, too. Concerned about his wellbeing, I sometimes slept in his hospital room. After nine months of treatment, Guy was finally able to breathe and eat normally.4

  From the time he left the hospital before his first birthday to now, Guy and I have stayed in touch. When he was six years old, he visited my family in Cincinnati. (He still remembers playing with my twin daughters.) Today, Guy is a paramedic and emergency-medical-services instructor. He has told me that he went into the medical field after he understood how I had helped him as a surgeon and was dedicated to doing all I could to ensure his survival.

  Figure 9.7. A young patient: In 1966, nine-month-old Guy Carpico has a new esophagus so he can swallow food and liquids. (From staff photographer/New York Daily News.)

  By the early 1970s, I had performed the reversed gastric tube operation on more than fifty patients and had published in medical journals more than twenty-five scientific papers on the reversed gastric tube operation.5 The operation became the standard procedure for dysphagia and was performed by surgeons around the world.

  Prior to my development of the reversed gastric tube operation, researchers had been experimenting for more than fifty years, trying to help patients with a blocked or destroyed esophagus to be able to swallow food. What led to patients being able to perform the simple act of eating a sandwich was the fact that I had zeroed in on the problems that had limited these early pioneers and then figured out a way to overcome those obstacles.

  Yet, back when I began performing the procedure, I learned an astonishing fact: I was not the first surgeon to do it. In October of 1955, I received a letter from a physician in a country that had been cut off from the rest of the world, informing me of this fact. That discovery led to an incredible journey to Eastern Europe.

  While I was working on developing the reversed gastric tube operation, it never occurred to me that another surgeon had come up with the same procedure. But in October 1955, I received a letter from Dr. Dan Gavriliu from Bucharest, Romania. He said that he had read in a medical journal about my reversed gastric tube procedure and wanted to inform me that he had been performing it since 1951.

  Considering where Dr. Gavriliu lived, it’s no wonder that I had not heard about his work. During the Cold War between the United States and the Soviet Union, Romania had been isolated behind the Iron Curtain. Most publications from outside the country never reached the USSR, but certain international publications were allowed in. Dr. Gavriliu had read an abstract of the 1955 Surgery article in International Abstracts of Surgery.1

  Dr. Gavriliu and I began exchanging letters. He explained that he had first performed the procedure on April 20, 1951, four years before I had done so. Writing in perfect English, he invited me to Romania as a guest of government-controlled Society of Medical Science. He said he wanted us to get together to compare our experiences and even operate alongside each other. Because our two countries had no diplomatic relations, there was no Romanian embassy in Washington; however, there was, he informed me, a Romanian legation, and a travel visa awaited me should I decide to accept his offer.

  Figure 10.1. Getting ready for an unusual trip: Jane and I were excited about the prospect of being permitted a rare glimpse behind the Iron Curtain. (From “New Rochelle Surgeon to Visit Iron Curtain Land,” Standard-Star [New Rochelle, NY], Saturday, September 15, 1956.)

  What an opportunity, I thought. I had become so used to American doctors refusing to acknowledge the success of the reversed gastric tube procedure. Also, I was not aware of any other American scientist or doctor who had been permitted to enter Romania.

  At the time I received Dr. Gavriliu’s letter, Romania—or the Romanian People’s Republic, as
it was then called—was a Communist, Soviet-aligned, Eastern Bloc state. When World War II ended, Romania’s economy was in decline, partly due to its having to pay war reparations to the Soviet Union. In the 1950s, however, Romania’s Communist government began to assert more independence and induced the withdrawal of all Soviet troops by 1958. During this period, many people were executed or died in custody. While judicial executions between 1945 and 1964 numbered 137, deaths in custody are estimated in the tens of hundreds of thousands. Many more were imprisoned for political, economic, or other reasons and suffered abuse, torture, and, very often, death.

  In early spring of 1956, I accepted Dr. Gavriliu’s invitation, making two requests: I wanted to bring Jane, and I also wanted the operation filmed. Both requests were granted.

  “I hope your honoured wife and yourself will enjoy the voyage,” Dr. Gavriliu wrote in a letter dated July 17, 1956.

  OFF TO ROMANIA

  Getting to Romania involved a circuitous series of flights. We first flew from New York to West Berlin, then we crossed the border into Communist East Berlin by walking through the famous Brandenburg Gate next to the Berlin Wall. After a brief hassle with the Communist bureaucrats, they stamped our passports with East German visas. We then caught a flight on the government-controlled Air Romine and boarded a twelve-person, twin-engine propeller plane to Bucharest.

  Figure 10.2. Ready for takeoff: A number of newspapers covered our trip because it was highly unusual for outsiders to be allowed into Romania. (From the Daily Item [Port Chester, NY], Tuesday, September 25, 1956.)

  On arrival at the Bucharest airport, we were greeted by a group of officials and physicians, including Dr. Gavriliu. He was a thin, good-looking man about my age, thirty-six. Young girls dressed in Romanian peasant costumes presented flowers to Jane. To us, two Americans who had little idea of what goes on in authoritarian regimes, it seemed as if we were going to have a pleasant, relaxing time. We checked in at the AthÈnée Palace, a comfortable, old hotel on a square.